Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client prior to disclosure of information in six of ten client records.The findings included:Ten client records were reviewed on August 26-27, 2014. Ten client records were required to document an informed and voluntary consent from the client prior to the disclosure of information. Client #1 was admitted to treatment on August 21, 2013 and was discharged on January 31, 2014. A release of information for a funding source was signed on August 21, 2013 and November 21, 2013, but did not include a relevant purpose. In addition, this client record included a progress note for another client.Client #3 was admitted to treatment on October 10, 2013 and was discharged on May 2, 2014. A release of information for a funding source was signed on October 10, 2013, January 10, 2014, and April 10, 2014, but did not include a relevant purpose.Client #4 was admitted to treatment on October 21, 2013 and was discharged on April 4, 2014. A release of information for a funding source was signed on October 21, 2013, and January 21, 2014, but did not include a relevant purpose. Client #6 was admitted to treatment on January 16, 2014 and was discharged on June 20, 2014. A release of information for a funding source was signed on January 16, 2014 and April 17, 2014, but did not include a relevant purpose.Client #7 was admitted to treatment on March 26, 2014. A release of information for a judge was signed on March 28, 2014, but did not indicate the specific information to be disclosed.Client #8 was admitted to treatment on April 24, 2014. A release of information for a funding source was signed on April 25, 2014, but did not include a relevant purpose. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Consent to Release Information form will be revised by the Clinical Coordinator to ensure that the consents will include the following: Purpose for funding area to be checked by the client.
The team of Clinical Supervisors will then train all clinical staff in completing the revised consent to release information form. The training will be documented and placed in the staff personnel file within the next sixty days, from the date of the exit interview. The Quality Assurance Director includes reviews of Consent to Release Information forms in the quarterly audit.
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